Patient Centered Medical Home Program Baccalaureate Nursing Practicum

Lead Organization

Whitney M. Young Jr. Health Center, Inc.

Joint Applicants

Hudson Mohawk Area Health Education Center

Areas Project Intends to Serve

Capital District

Overview

Whitney M. Young Jr. Health Center, Inc., and Hudson Mohawk Area Health Education Center intend to develop a program which will provide regional nursing students in baccalaureate programs with the monetarily-incentivized opportunity to learn Patient Centered Medical Home (PCMH) related concepts during their clinical capstone practicum at Whitney M. Young. Currently, there is a shortage of PCMH knowledge and skills both within the Whitney M. Young network as well as the regional applicant pool in general, as very few nurses elect to pursue training. As such, the creation of such a program could greatly improve population health outcomes across a variety of DSRIP measures, from preventative health to behavioral health to avoidable hospital use, given that PCMH-related concepts include care coordination, team-based practices, as well as enhanced access to continuous and comprehensive quality care, health information technology, and value-based payment reforms.

DSRIP Measures Addressed

  • Preventative Health
    • Primary Care Visit (All Ages)
    • Well Child Visit (All Ages)
  • Behavioral Health
    • Antidepressant Medication Management – Acute
    • Antidepressant Medication Management – Continuation
    • Anti-psychotic Med Users with Diabetes Screening
    • Cardiovascular Disease Schizophrenics with CVD Monitoring
    • Engaged in Substance Abuse Treatment
    • Discharge with Timely Follow-Up – 7 Days
    • Discharge with Timely Follow-Up – 30 Days
    • Potentially Preventable Emergency Visit
    • Schizophrenics with Antipsychotic Medication Adherence
    • ADHD Medication with Timely Follow-Up – Initial
    • ADHD Medication with Timely Follow-Up – Continuation
  • Avoidable Hospital Use
    • Potentially Preventable Admissions – Child
    • Potentially Preventable Admissions – Adult
    • Potentially Preventable Emergency Department Visits
    • Potentially Preventable Readmissions